Open defecation by around 600 million people has been called our biggest national shame. The latest Census data (2011) reveals that the percentage of households having access to television and telephones in rural India exceeds the percentage of households with access to toilet facilities.

India has a massive problem of open defecation. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) estimate that there are more than 620 million people practising open defecation in the country, or half the population. Open defecation is prevalent among all socio-economic groups in rural India though the bottom two wealth quintiles bear the heaviest burden. Children—already vulnerable and marginalized—pay the highest price in respect of their survival and development.

This well-established traditional behaviour is deeply ingrained through practice from early childhood; it is taught. Other reasons cited for its persistence in India include poverty (the inability to afford toilets), landlessness, tenants in housing without toilets (usually urban), and deep-rooted cultural and social norms that have established open defecation as an acceptable practice.

India is home to the largest number of children in the world—nearly 500 million Indians are less than 18 years of age. India loses more than 600,000 children under the age of five year due to diarrhoea and pneumonia—almost 30% of the global total. Bacteriological contamination, the absence of toilet-use and woefully poor personal and communal hygiene (including no habitual hand-washing with soap at critical times) exacerbate both of these killers; 88% of diarrhoea deaths are linked to incomplete water and sanitation service provision.

India has the largest number of stunted children in the world with almost half of all children moderately or severely underweight; indeed, stunting is thought to contribute to over a third of under-five deaths globally. The period when a child is most vulnerable is during its first 1,000 days. Stunting has lifelong effects that manifest physically, economically, and socially. The effects include both a reduced growth rate and a lower weight than the standard for the general population of the same age and gender.

Many stunted children also show impaired cognitive ability and perform less well than their peers at school. In a landmark “Viewpoint” article in Lancet, Jean Humphrey hypothesizes that the primary causal pathway from poor sanitation and hygiene to under-nutrition is environmental enteropathy and not diarrhoea. Environmental enteropathy is a subclinical disorder that occurs among people with poor or inadequate access to water, sanitation and hygiene.

The government, with technical support from UNICEF, has focused on the need for a strong interpersonal approach to generating and sustaining demand in rural India around four key issues: use of toilets, washing hands with soap, safely disposing child excrement and finally safely storing and handling drinking water. Such initiatives, especially at the community level, where the entire community together realizes the need, can lead to rapid acceleration in sanitation and hygiene. But this needs intensive follow-up at ground level, as we have seen from our work in states such as Madhya Pradesh, Rajasthan, Assam and Odisha.

Each year nearly 20 million people are starting to use a toilet—breaking the inter-generational habit that was taught to them as toddlers. But, quite simply, 20 million new users a year is not enough to ensure that all children are born into an environment that will not contribute to them being stunted; where they will no longer suffer from repeated episodes of diarrhoea; and where girls will be free from harassment and embarrassment as they enter puberty.

Using a clean, working toilet is about health and also about dignity.

UNICEF is organizing a nationwide online communication campaign aimed at raising the most powerful voice of the nation: the voice of youth, which will be launched next month. The idea is to reach urban young people primarily, the majority of whom will already use a toilet, and create an active layer of advocates who can speak out to stop open defecation, further disseminate the message and influence their communities, families and peers to do the same. Collectively this voice will help to stimulate the creation of a new social norm—an India where nobody accepts open defecation and everyone uses a toilet. Thus, the task is to create noise that makes the nation sit up, take notice and join UNICEF in its efforts to make India poo-free. Ultimately, it is about realizing that everyone is affected by open defecation—whether you use a toilet or not!